ambulatory nursing triage development - mc.vanderbilt.edu · triage recordsaudits • integrate...
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• <50%ofcancerrelatedcallsareresolvedatinitialpointofcontact
• >30%ofpatientsymptomsdonothaveaprotocolinplace
• Bothfactsabovesupporttheneedfor:- Additionalprotocols(i.e.,edema,congestion,mentalstatuschanges)
- Annualrevisionofexistingprotocolstobroadennursingscope
• Continuationofquarterlynursetriageaudits
• Integrateclinicandtriagenursesintomeetingstodefineroles/expectationsandresolveissues
Access Redesign Methodology
Protocol Development Process
Telephone Nurse Triage Model
• Thisprocessconsistedofateamofnursesandprovidersfrommanyareasofexpertiseutilizingevidence-basedpracticeguidelines.
• InconsistentapplicationofprocessesandstandardsfortriagingpatientphonecallsintheVanderbilt MedicalGroup(VMG)ambulatoryenvironment• Lackofestablishedguidelinesforaddressingpatientphonecalls• Variableandinconsistentlevelsofcare-advicebasedonnursingexperience,notonevidence-based practiceguidelines• Inconsistentandinformalprocesstomanagepatientcalls,whichresultedin:• Delayofpatientcare
• Symptommanagementbasedonurgency• Medicationmanagement• Numerousquestions/concerns
• Callmanagementsystemthatwasnotmeasurable;inabilitytotrack/identifynurse-relatedphonecalls
VMGconsistsofapproximately125ambulatoryclinicsthroughoutthecommunityandsurroundingareas,whichgenerateover1millionpointsofcontactannually.• Progress:todate,theclinicsthathavehad
PerformanceImprovementOffice(PIO)involvementequalonly23%oftheannualvisitvolume.
• RemainingEfforts:77%ofclinicvolumeremainsasworktobecompleted;inwhichthereisnoabilitytoself-selecttospeakwithalicensednurseordistinguishbetweencalltypes.
THE SCOPE:
THE PROBLEM: THE METHODOLOGY:
Evidence-Based Telephone Nurse Triage Protocols:
FINDINGS & RESULTS:
CONTRIBUTORS:StephanieHyde,RN,ADNHelenaBruner,RN,BSN,OCNPatriciaMyers,RN,BSNDebbieBrandle,RN,ADN,OCN
SusanCosenza,RN,BSNDauphneMcGavic,RN,MSNCherylBates,BS,CentralAppointmentSchedulerAmySpence,CentralAppointmentScheduler
Access Model Triage Model
• BEFORE:Fromaninformalsystemwithnumerouslevelsofundefinedrolesandfunctionality
• AFTER:Toastandardizedsystemwithwelldefinedrolesandfunctions
• Atpointofcontact,patientsaregivenatimelyplanofcareandappropriatedisposition.
Work Thus Far
• Protocolsinclude:1. Bleeding2. Constipation3. Diarrhea4. Dysphagia5. Fatigue/Malaise6. Fever7. Nausea&Vomiting8. Pain9. Mucositis/Xerostomia10.Rash/SkinIrritation11.Drains
Access Center Nurse TriageTransition to Current State
Total Call Volume for Vanderbilt Cancer & Breast Access Centers
23,22722,375
23,85222,380
2328224509
21205
2454023510
22422 2259821863
2389822901
0%
5%
10%
15%
20%
25%
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
22,000
24,000
26,000
Total Access Center Calls Abandoned %
Breakdown of Nurse Triage & Scheduling/Ancillary Call Volume for Vanderbilt Cancer & Breast Access Centers
14842 1455616290 15102 15912 16053
1383415834 15578 14884 15166 14050
15740 14832
8385 78197562
72787370 8456
7371
8706 7932 7538 74327813
81588069
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
0
5,000
10,000
15,000
20,000
25,000Scheduler & Ancillary Calls Nurse Triage Calls Abandonment Rate
Telephone Nurse Triage Audit ResultsPatient Call Status
Emergent2.3%
Urgent20.4%
Non-Urgent & Home Care
77.3%
Triage RN CompletesPatient Encounter
25.1%
Further Action Required by
Clinic RN44.8%
Further Action Required by NP/PA
22.1%
Further Action Required by MD
8.0%
Telephone Nurse Triage Audit ResultsPatient Encounters - Level of Completion
Telephone Nurse Triage Audit ResultsCall Type
PriorAuthorizations
2.9%Ancillary
Groups 4.0%
Prescription Requests 3.0%
Orders 6.1%
Appt/Test Scheduling19%
Call Back 18.1%
Results11.3%
MedicalRecords
Issues 4.2%
Medication Question6.0%
Symptom/Sick 16.0%
Telephone Nurse Triage Audit ResultsProtocols Used
Bleeding2.9%
Constipation4.1%
Diarrhea4.6%
Dysphagia0.9%Fatigue/Malaise
3.7%
Fever5.2%
Mucositis2.2%
Nausea/Vomiting8.0%Rash
1.2%Drain0.6%
Pain32%
Other (Specify in comments)
36%
AMBULATORY NURSING TRIAGE DEVELOPMENTESTABLISHING CONSISTENT EVIDENCE-BASED STANDARDS OF NURSING CARE
AUTHORS:NancyMuldowney,MLAS,BSN,RN;JenniferMitchell,MSN,ANP-BC,GNP-BC
Vanderbilt-Ingram Cancer Center
Transition
The Vanderbilt-Ingram Cancer Center (VICC)isaleadingmulti-siteoncologycenterwithover6cancersub-
specialtiesandmorethan90providers.NotonlyistheonlyNationalCancerInstitute-designatedComprehensive
CancerCenterinTennessee,itisalsoamemberoftheNationalComprehensiveCancerNetwork,anon-profit
allianceof21leadingcentersworkingtogethertoimprovequalityandeffectivenessofcancercare.
Access Center Clinical Calls
Common EBP Nursing Assessment & Questions
Patient Has Options at Point of Contact
Plan of Care Clarification
Questions & Follow Up
Protocols &
Directives
Rx Renewals
& Med Mgmt
CAS PSR
Back Lines
AA & OA
Clinic Primary Outbound & Multiple Call Backs,
Patient Delays
•HandOff•Message
•HandOff•Message
•HandOff•Message
•HandOff•Message
VICC6%
Urology2% Breast
Center1%
Women'sCenter
3%
WilliamsonPrimary
Care4%Otolaryngology
5%
GeneralSurgery
2%
All Other77%
Nurse Triage
Nurse TriageCentralizedClinicalEffectiveEvidence-Based Protocols
DedicatedStaffPatient-CentricMeasurable
• FourKeycomponentsareincludedinthecentralizationofaccess.TheNurseTriagecomponentaddressesqualityofcarebaseduponnationalstandardsandguidelines.
Before After